The economics of mental illness

Make Me Smart December 7, 2021 transcript

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Kimberly Adams: Right on it, too.

Kai Ryssdal: No joke. Hey, everybody, I’m Kai Ryssdal. Welcome back to Make Me Smart, where none of us is as smart as all of us. It’s really good to have you back on the pod.

Kimberly Adams: And I am Kimberly Adams, It’s Tuesday, which means it’s time for our weekly deep dive into a single topic, and today we wanted to talk about the economics of mental health. So obviously, we are in the second winter of this pandemic and the dreariness and the oh, my god, we are still here, and we have a lot more awareness about how our mental health affects our physical health as well as our work and how we function in society and the economy. In the summer of 2020, US adults were about three times more likely to experience depression or anxiety as they were the summer before the pandemic.

Kai Ryssdal: Turns out businesses, parts of government as well, have started to think about how mental health maybe is as important as physical health, as Kimberly said. So today we’re going to get smarter about some of the costs, both human, but, but indirect economic costs of mental health and the challenges that we’re all having right now. Here to help us do that is Judy Bass. She’s an Associate Professor in the Department of Mental Health at the Johns Hopkins University Bloomberg School of Public Health. Welcome to the show. Good to have you on. 

Judy Bass: Thank you very much for having me today.

Kai Ryssdal: Let me pick, pick up on something Kimberly said there in her bit of the introduction. We’re heading into the second winter, are you worried as a mental health professional?

Judy Bass: Well, I was worried as a public mental health researcher and professional before the pandemic. So even before the pandemic, we knew mental health problems were costing businesses and were prevalent. I think the continued pandemic has raised the awareness, as you said, and that people are getting tired. So we talked about sort of disorders, the high rates of disorders, those have increased over time, they’ve increased in the last decade. But the distress, the symptoms of depression, the symptoms of anxiety, continue to be a burden on all of us, whether or not we are dealing directly with the disease and COVID itself, but just the, the wear and tear of life right now.

Kimberly Adams: So yeah, it sucks. Great. But with, with that, and knowing sort of the individual toll, why should businesses and companies and economists care about this specifically, especially as it relates to the unique mental health situation brought on by the pandemic? 

Judy Bass: Sure. So, what we know is that the economic costs of mental illness and mental health conditions broadly fall into sort of two buckets, or oftentimes fall into two buckets. One is the treatment. And so, you know, there’s the costs associated with inpatient and outpatient and emergency room use, and sort of that whole side of the cost of health care. And oftentimes, that’s underestimated for mental health conditions because of the high comorbidity between mental health conditions and other chronic health, like the association between high rates of diabetes and hypertension and depression, people with depression, often have poor adherence, and can have poor outcomes if they have comorbidity. 

Kimberly Adams: Wait, I’m sorry, what do you mean by that? What do you mean by that?

Judy Bass: What do I mean by that is that some of the symptoms of depression can make people less likely to engage in like, the things of daily life. Like we talked about, you know, not wanting to go to, not wanting, not thinking about the future, not planning for the future. And if someone has another illness, like needs to take their insulin or needs to take their hypertension drugs, then sort of the depression might interfere with taking those medications, with taking care of themselves if they have a co-occurring physical health condition. So that can increase the cost, the lack of, you know, if there’s port costs, if there’s costs of mental health care, there’s also costs associated with other chronic illnesses connected with the mental health. So that’s one side of the equation. But in terms of the business side of the equation, untreated or undertreated mental health conditions related to increased absenteeism in the workplace, what they call presenteeism, which is being present but lower productivity, and also higher turnover rates. And so business should be concerned about this because it does affect their bottom line, both not providing good mental health care, but also being concerned about how our healthcare system is, is not providing sufficient resources and funds for good mental health care.

Kai Ryssdal: So what do you suppose accounts for the underinvestment, both in our society at large but also on the part of businesses through corporate health plans or what have you, that underinvestment that we have been making now, if I could mangle the phrase, for decades, right, it just, mental health just hasn’t been as important as, oh, you got to stay physically healthy.

Judy Bass: So I think there are multiple structural factors. And one of them though, a big one, is the issue of stigma. There has been a long history of, of mental health problems being stigmatized, both from the outside in, so just suck it up and do your work, it’s all in your mind, it’s not a real illness. Sort of that face. But also internally, I, you know, people with mental illness often are, feel themselves, like maybe it’s something about them. And so I think the issue of stigma is a real barrier to getting access. So I think that’s one side of it. And the truth is, mental health conditions are treatable. They are a health problem that is legitimate and real. And so I think the, the issue of stigma has made it so there is a lack of utilization. There’s also discrimination against people with mental health conditions historically. And so that has reduced it. But I also think our structures, the health system, has not frequently paid as much on reimbursement for, for mental health. And for psychiatry, there’s a real lack of available providers because mental health and psychiatry and social work has not been seen as a good, as good or lucrative field for professionals to go into. And so I think it’s at multiple levels that we’re missing out on, on meeting the need and getting people who need the services into treatment.

Kimberly Adams: Can I ask you to expand on that a bit, because we hear so much about the provider shortage. Like, obviously, as you laid out, there’s been growing need for a long time, it spiked during the pandemic and people are still dealing with these consequences and needing mental health care, but there just are not enough people to do it. What’s behind that shortage? You said that the reimbursement rates are not the same, what else is going on there?

Judy Bass: So I think this is true for a lot of health conditions, we’ve got a lack of primary care providers for a lot of health conditions. Mental health is more exacerbated, but it’s not unique to mental health. So I think the gaps in our health access and available providers is something that is true across the board. When it comes to mental health, I think some of it is structures. There’s psychiatry, where we don’t have enough people going into psychiatry, but then there’s also psychology and social work. And that, I think people become very specialized and so there is not as many providers. I think, in my own opinion, but also from the research that there is a lack of appropriate services at all levels. So what we need are providers in the schools for prevention, what we need are counselors and social workers at, at the community level, so that people can get early services, so they don’t need to go up to the psychiatric services. What we need are full level structures of care that allow for people being referred up and down who need more, who need less. But those, those, the training, the training opportunities are out there. But I think some of the barriers, as you mentioned, are the reimbursement issues have been a real barrier. And the amount of money put into health care packages for reimbursing mental health has been a big, a big piece of it, trying to get mental health equity in the healthcare packages could then move us towards more people getting trained to provide these certain services. 

Kai Ryssdal: Not to be, you know, dollars and cents about this, but there, is the ROI on investment in mental health tangible, if that makes any sense? You know, do we see more people showing up for work? Do we see better performance and all of those things?

Judy Bass: We do. We do. I think, you know, there was a, an article put out by McKinsey Consulting recently, last December, 2020, on employees demanding better coverage from their employers and CEOs who normalize mental health and reduce stigma and put efforts into mental health care, so wellbeing, the positive sides of mental health, but also providing easier access to mental health services at all levels, are seeing reduced turnover, seeing reduced presenteeism, more people being productive because they are feeling better, they’re able to be more productive, and reduced absenteeism.

Kai Ryssdal: Yeah, sorry, just to jump in here real quick. They have to be real, though, these moves that companies make. They can’t just be platitudes because–

Judy Bass: Absolutely, they have to increase actual access to services. It’s not just providing a list here, go see this, it’s actually helped facilitating and reducing the barrier to seeking services, giving people the time they need to get services. So as we talk about CEOs and business saying, you can take a day off after your COVID vaccine because we want you to get vaccinated, they should have those same conversations. If you need this, if you need mental health care, go get it so that you can be more productive and, and a better part of our team, healthy.

Kimberly Adams: You’ve looked at, in your research, strategies to improve mental health services and access in different parts of the world. Are there things that other countries are doing that are working and successful and you can just say, yes, we should do that here?

Judy Bass: Yeah, actually, one of the things that I think is an important innovation that we’re doing in the global context is the use of task sharing providers. So we are using people with at the community level, community health workers, people with less formal training or even no formal training to provide direct mental health service that are supervised by people with more mental health training. And then those people are supervised by psychiatrists and psychologists. And so this multi-tiered approach is being able to reduce some of the treatment gap. And that could be implemented here. But we have some barriers around licensure, around HIPAA, around reimbursement, but, but they can be piloted, and they could be innovative here.

Kimberly Adams: And have you seen any moves in that direction?

Judy Bass: I have, there are some places. So some of the, some of the behavioral health, some of the substance use treatment sites are doing things, they can provide a package of care and get reimbursed. And so in that package of care, they have peer providers, they have community health workers, and so they can do that as part of their package to getting reimbursed. So that’s how we’re getting over the reimbursement rate and reach more people with the appropriate services.

Kimberly Adams: Judy Bass is an associate professor in the Department of Mental Health at Johns Hopkins Bloomberg School of Public Health. Thank you so much. 

Kai Ryssdal: Judy, thanks a lot. 

Judy Bass: Thank you. 

Kimberly Adams: And we would like to hear from you on that as well. How was your 2021, really? What are you looking forward to in 2022? Let us know, our number is 508-827-6278, also known as 508-82-SMART, or leave us a voice memo at makemesmart@marketplace.org. I have to say, Kai, I’ve had so many conversations with friends about mental health in the pandemic and just lots of people go into therapy for the first time, going back to therapy for the first time, wishing they had access to therapy, struggling to find therapists. And yeah, it absolutely does affect how people show up at work. 

Kai Ryssdal: Sure. It’s, it’s absolutely real. And I think, and I’m going to steal a news item from you, I think, but did, did, did you hear Vivek Murthy on Morning Edition this morning?

Kimberly Adams: I didn’t hear him but I saw the announcement. 

Kai Ryssdal: Yeah, it’s, it’s really interesting. So these, the, the Surgeon General in the United States, Vivek Murthy, came out with an announcement about mental health initiatives. But more importantly, in this interview with Steve Inskeep on Morning Edition this morning, he talked about his own experiences as a kid being challenged by mental health issues, and it’s, it’s everywhere. And it’s not a sign of weakness to ask for help. It’s just not. And that’s, the stigmatization, I think, is the worst part.

Kimberly Adams: Yeah, and one of the, I mean, I always hate this phrasing, one of the good things about the pandemic, because none of it’s really good. But in the, you know, push for more telehealth, there’s been a really interesting expansion in mental health apps and online therapy options. And, you know, even our company started offering virtual mental healthcare during the pandemic through one of these apps and services. And so I think not having to go to somebody’s office where people can see you go in, especially if you’re in a place where you don’t feel comfortable doing that, and being able to get therapy from home, I think it’s really helped a lot of people. 

Kai Ryssdal: Yeah, totally agree. 

Kimberly Adams: Yeah. But we do want to hear from all y’all about your thoughts on this and other things. Like I said, 508-UB-SMART.

Kimberly Adams: Okay, time for that news fix that Kai has already mentioned. 

Kai Ryssdal: Well, it was, it was—

Kimberly Adams: It was relevant. It was relevant. It’s fine. It’s fine.

Kai Ryssdal: Go ahead. Go ahead.

Kimberly Adams: Right. So today, the US Surgeon General issued an invite, an advisory on a, on the Youth Mental Health Crisis further exposed by the COVID-19 pandemic. And basically, this is just, it’s a big report, I think it’s, what is it, like, 53 pages or something like that? It’s, it’s a big report basically drawing attention to the fact that kids are really suffering and, and, according to this report, up to one in five children ages three to 17 in the US is having, are having a mental, emotional, developmental or behavioral disorder before the pandemic, and now it’s even worse. And I’m just going to read from the LA Times write up of this because they’ve got a good consolidation of the numbers. Symptoms of depression and anxiety have doubled during the pandemic, with 25% of youth experiencing depressive symptoms and 20% experiencing anxiety symptoms. There also appear to be increases in negative emotions or behaviors such as impulsivity or irritability. And then it goes on to say, in an early 2021, emergency department visits in the US for suspected suicide attempts were 51% higher for adolescent girls and 4% higher for adolescent boys compared to the same time period in early 2019, based on research that was cited in that report. And the pandemic and everything it did to kids and teenagers just exacerbated these trends that were already happening. They couldn’t be around their friends in person, missed out on a lot of milestone. And it’s just a risk. It’s, it’s something worth paying attention to. And look, it’s not like the Surgeon General is, has a lot of tools at the disposal of that office to do something about it other than raise awareness. But these are important things to just look at. Yeah, we’ll have some additional resources around this on the show page. But just another reminder that if you’re hurting and you need some help, you can call the National Lifeline at 800-273-8255. If you need to talk to somebody, if you’re in distress, 800-273-8255.

Kai Ryssdal: Yeah, I’m going to exercise those prerogative here and bail on my news items because I just want to keep the top of this pod sort of on a theme, right, and how critical these issues are. And when you’ve got that 44% increase that Kimberly was talking about, you know, we got to pay attention. We got to pay attention. That’s it. Charlton, hit it. Alright, here we go, your comments on a bunch of stuff. Number one, audio is everything, so pronunciation matters. Go.

Leah: Hi, this is Leah from New Jersey. I am fluent Greek language speaker. And the way to say the name of the new variant is Omicron. That’s in the Greek accented language. And I want to say I love the show. Bye.

Kai Ryssdal: Alright, you know what, that was not incredibly helpful because it’s a little bit Omicron and it’s a little bit Omicron. Now what do we do?

Kimberly Adams: And neither one of those is what we were taught to say.

Kai Ryssdal: I know. I know. Leah, God bless you for writing in or calling us, but oh, man.

Kimberly Adams: The Wall Street Journal had a whole piece which I think the headline was something like, no matter how you’re saying it, you’re saying it wrong. Great, okay. Last week, we also talked about all of the junk, AKA orbital debris, up in space. And we got this voice memo.

Robert: Hi, guys. This is Robert calling from Williamsburg, Virginia, and listening to your program from yesterday, the Enneagram day and the reference to space junk, and being a person who cleans it up I think that would be an extremely cool job. I don’t know how much you’d make, but time and space looking back at the blue ball and all you’re doing is picking up trash. That’d be an awesome job. That’d be very cool. Thanks a lot, guys. Have an awesome weekend, bye-bye.

Kai Ryssdal: Although I will tell you, I had a little pang of jealousy yesterday when the, when the new astronauts were announced, the folks that are gonna do the Artemis moon landings, in theory, in 2025 and beyond, I was a little jealous, I was a little jealous. I was like, you know what, number, well, number one, I’m out of the age range, age range, but number two, man, that’d be cool. That’d be cool.

Kimberly Adams: I get jealous every single time and not a little bit jealous. Like full, full on jealous. I mean, God bless him. I don’t like, you know, not trying to be covetous or anything but like, I’m jealous. 

Kai Ryssdal: I’m straight up covetous. I don’t care. I’m gonna own that.

Kimberly Adams: There’s a commandment against that one.

Kai Ryssdal: That’s a whole different show. That’s a whole different podcast.

Kimberly Adams: No, but to Robert’s point, the job, though, it was, it was a make-believe job, I should say. It was from the anime planetaries that I was talking about. But in the anime series in which people had this job, it was actually like, a terrible job that no one wanted and like, all of the people who like, failed at being astronauts ended up with that job. But I’d totally do it. Totally do it. Okay, now it’s time for the answer to the make me smart question, which is what is something that you thought you knew you later found out you were wrong about? This week’s answer comes from Susan Wojcicki, who I recently interviewed on Marketplace tech. She’s the CEO of YouTube.

Susan Wojcicki: You know, I think one of the things I’ve learned a lot, and it comes to really anything that was really insightful for me, is no matter how much you know, something you could know it better. I think about that all the time because I realized that when people ask really basic questions, those aren’t stupid questions, that a lot of times like, the most basic questions are the ones that are in many ways, like the most insightful and are actually the hardest. 

Kai Ryssdal: That’s a good answer. I like that one.

Kimberly Adams: I just hope she didn’t think the questions I was asking were stupid questions. She thought they sounded stupid, but really insightful.

Kai Ryssdal: Really hard.

Kimberly Adams: If you’ve never answered the make me smart question, there is no better time than now. Send us your answer in a voice memo to makemesmart@marketplace.org or 508-827-6278, also known as 508-82-SMART.

Kai Ryssdal: Still taking questions, we are, for tomorrow for what do you want to know Wednesday. Or start thinking about questions you want us to answer for you in the new year because that’s like, around the corner and just, you know, send us your stuff, comments, thoughts, questions. Whatevs. 

Kimberly Adams: This year flew by, unfortunately.

Kai Ryssdal: Make Me Smart is directed and produced by Marissa Cabrera. Marque Greene helps produce the show as well. Our intern is Grace Rubin. Tony Wagner writes our newsletters.

Kimberly Adams: Today’s program was engineered by Charlton Thorpe with mixing by Jayk Cherry. Ben Tolliday and Daniel Ramirez composed our theme music. The senior producer is Bridget Bodnar. Donna Tam is the director of on demand and Marketplace’s Vice President and General Manager is Neil Scarborough. 

Kai Ryssdal: There we go. Another one in the books. 

Kimberly Adams: I loved anagram day. 

Kai Ryssdal: Yeah, it’s funny. 

Kimberly Adams: Somebody pointed out that for the DC folks there were like, multiple ways to find the 202-area code in that too.

Kai Ryssdal: Oh, for crying out loud. You guys need to get outside the beltway. That’s all I’m saying.

Kimberly Adams: Give us our small things. We can’t pass legislation. Let us have this. 

Kai Ryssdal: Oh, my goodness.